Time Based E/M Coding


Clayton, NJ
Best answers
My question has to do with when a dr has too much information in notes. This has to do when a dr has enough in office visit notes for 99214 or 99215.
I have a dr that has a scribe so he always has complete PFSH & Exam information. I have asked him to include the time in his notes to help me with coding. So if his time is 15 minutes but his notes are enough for higher is it considered down coding to bill 99213. I realize I need to read the notes as well. The other side if the notes are enough for 99214 but it has noted time of 15 minutes is it correct to bill as 99214 or should it be 99213?

Thank you for your help!
It sounds to me that if he "always has complete PFSH & Exam," you need to focus on medical decision making. Documented MDM will determine which CPT you will choose. If the MDM supports a 99214, then base your coding on the documentation. If the MDM supports a 99214, and 15 minutes of time is also documented, you can still code based on the MDM documentation. My understanding is that you are not tied to code based on documented time, as long as PFSH, Exam, and MDM documentation support the CPT. :)
In order to bill based on time, more than 50% of the face to face time spent with the patient has to be spent in counseling. For example a patient comes in to go over test results that may lead to surgery. The doctor may do a minimal exam but spend 30 minutes talking about the test results, the reason for surgery what other treatment options there are etc. In this case the doctor can bill based on time, but he must document the amount of time spent face to face with the patient, that more than 50% of this time was for counseling and summarize what was discussed with the patient.

As Barb mentioned, you should probably be focusing on the MDM. Including the time in the notes does not necessarily mean that it can be billed that way.
Also be mindful of medical necessity

The MDM is what several carriers are using to determine the medical necessity of the level assigned, so consider that as well. If the time and Hx/Ex allow for a high level code, but the MDM is low, that may bring down the level allowed.